Antiretroviral Treatment Costs in Mexico
Sergio Bautista, Tania Dmytraczenko, Gilbert Kombe and
Stefano Bertozzi
WHO/UNAIDS Workshop on Strategic Information for
Anti-Retroviral Therapy Programmes
30 June to 2 July, 2003
Assessment of programme outcomes (economic)
Purpose of the Study

To document—using a consistent methodology—the Mexican
experience in HIV/AIDS treatment in 3 health subsystems
– Ministry of Health (SSA)
– Mexican Social Security Institutes (IMSS/ISSSTE)
– National Institutes of Health (INS)
Presentation prepared by INSP, 30 June 2003
Specific Objectives of the Study

Identify patterns of HIV/AIDS care and treatment and
related costs by type of therapy received
– ARV triple therapy or not

To estimate the annual care costs per patient by
•Subsystems
SSA, IMSS/ISSSTE,
INS
•Care setting
Inpatient, outpatient
Presentation prepared by INSP, 30 June 2003
•Level of care
Specialized clinics, secondary
and tertiary hospitals
•Disease stage
CDC classification
CD4
Study Approach: Site selection


11 health facilities were selected
– SSA sites (5)
– IMSS/ISSSTE sites (4)
– INS sites (2)
 Level of Care
Geographic Location
– Mexico City (6)
– Highly specialized tertiary care
facilities (3)
– Guadalajara (2)
– Secondary care facilities (7)
– Cuernavaca (2)
– Specialized HIV clinic (1)
Presentation prepared by INSP, 30 June 2003
Study Approach: Sample size and eligibility

Convenience sample to reflect clinical and treatment criteria of
interest:
–
–
–
–

ARV recipients (75%)
Not on ARVs (15%)
Deceased (10%)
1062 patients randomly selected, with sample stratification
Patients eligibility criteria
– 18 years or older at first consultation
– Diagnosed with HIV and confirmed by Western, Elisa or laboratory
culture, or symptomatic AIDS
– Documented visit at a study site between 1/1/2000- 12/31/2001
Presentation prepared by INSP, 30 June 2003
Data Collection Instruments

Utilization (patient chart review)
– Socio-demographic characteristics
– Clinical events including outpatient, inpatient, labs,
drugs, surgical procedures and interventions

Unit costs (facility questionnaire)
– Existing unit cost data
• Facility- or subsystem-specific
– Micro-costing of AIDS-specific diagnostic tests and drugs
– Recurrent costs (except for AIDS-specific tests)
Presentation prepared by INSP, 30 June 2003
Data Collection Process

5 trained teams, each composed of an
economist and a MD/nurse

Data were captured retrospectively for a
period of 3 years from the date of last
consultation in the study period

Accuracy and reliability of data collection was
strengthened with real-time data entry in the
field and error checking interface
Presentation prepared by INSP, 30 June 2003
Characteristics of the Sample (n=1062)
Education
Primary or less
Secondary+
Higher
Mode of Transmission
Unsafe injection
Transfusion
Occupational risk
Sexual
Sexual Preference
Heterosexual, male
Homosexual, male
Bisexual, male
Presentation prepared by INSP, 30 June 2003
SSA
IMSS/ISSSTE
INS
(n=506)
30.0%
54.0%
16.0%
(n=496)
1.2%
3.0%
-95.8%
(n=404)
40.3%
45.5%
14.1%
(n=144)
9.0%
52.8%
38.2%
(n=175)
-5.7%
-94.3%
(n=127)
62.2%
29.9%
7.8%
(n=87)
26.4%
55.2%
18.4%
(n=69)
-2.9%
1.5%
95.7%
(n=44)
40.9%
43.2%
15.9%
Key Finding #1: There has been a progressive
and rapid uptake of HAART
Distribution of Patients by Type of Therapy
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
(n = 49)
(n = 138)
(n = 326) (n = 567)
(n = 496)
Mono
Double
Triple
1997
1998
Presentation prepared by INSP, 30 June 2003
1999
2000
2001
Key finding #2: Patients start treatment in
advanced stages, improvement is gradual
Distribution of CD4 Count
.003
year –1 (n = 319)
year 1 (n = 712)
year 3 (n = 140)
.002
.001
0
0
500
Presentation prepared by INSP, 30 June 2003
1000
1500
2000
Key Finding #3: Total costs are substantially
higher under HAART
US$
Average Annual per Patient Cost of Treatment
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Hospitalization
Outpatient visits
Lab tests
OI drugs + procedures
ARV drugs
-3
-2
-1
(n = 45) (n = 153) (n = 612)
1
2
(n = 792) (n = 459) (n = 201)
Years pre- and post-HAART
Presentation prepared by INSP, 30 June 2003
3
Key Finding #4: Lab tests and Outpatient visits
are the largest contributors to treatment costs,
excluding ARVs
US$
Average Annual per Patient Cost of Treatment, Excl. ARVs
900
800
700
600
500
400
300
200
100
0
Hospitalization
Outpatient visits
OI drug + procedures
Lab tests
-3
-2
-1
(n = 45) (n = 153) (n = 612)
1
2
(n = 792) (n = 459) (n = 201)
Years pre- and post-HAART
Presentation prepared by INSP, 30 June 2003
3
Key Finding #5: Treatment costs are higher for
patients in advanced stages of illness
Avg Annual per Patient Cost of Treatment Excl. ARVs, by CD4 count
CD4 Range
0-199
Outpatient
Hospital
Lab
OI drugs+
visits
days
tests
procedures
Total
190
104
759
91
1144
205
36
603
30
874
279
23
566
21
888
271
8
496
61
836
(n = 1016)
200-349
(n = 484)
350-499
(n = 270)
>500
(n = 306)
Presentation prepared by INSP, 30 June 2003
Summary

Our findings are consistent with studies done in other countries
– ARV comprises >75% of total treatment costs
– Outpatient and monitoring costs increase as patients start
triple therapy

Unlike Sub-Saharan African countries, hospitalization is not a big
factor in Mexico

Costs associated with late initiation of treatment and during last
year of life
Presentation prepared by INSP, 30 June 2003
Policy Recommendations I

Governments should be realistic about resource requirements
of starting and scaling-up ARV treatment
– Lab capacity
– Human resource training

Countries should be prepared for the shift in care and
treatment patterns of patients on HAART especially
from inpatient to outpatient

Clinicians should clearly understand when to initiate and
how to monitor patients on therapy
Presentation prepared by INSP, 30 June 2003
Policy Recommendations II

Estimating total cost of ARV treatment can significantly
help countries plan for scaling-up
– Negotiating drug prices

Medium to long-term prospective is needed for a full evaluation
of program costs
Presentation prepared by INSP, 30 June 2003
Presentation prepared by INSP, 30 June 2003